Understanding trends and variation in paediatric fracture management in England

Sarah Lucas

07 August 2024

Background (continued)

Epidemiology of paediatric fractures

One hospital in Ireland calculated a paediatric fracture incidence rate of approximately 29 fractures/1,000/year1. The most common fracture was distal radial/buckle fractures (27.2%), followed by distal humerus /supracondylar fracture (13.9%), ankle fractures (9.2%), phalanx fractures (8.3%), and radial/ulnar metaphysis fractures (5.7%). It is suggested the incidence rate will depend on the social emphasis on encouraging physical activity1.

Between 2012–2019, 368,120 children under 18 were admitted to English NHS hospitals with a fracture; 256,008 (69.5%) were upper limb and 85,737 (23.3%) were lower limb fractures2. The annual incidence of upper limb fractures was highest in children aged 5–9 (348.3 per 100 000 children).

Paediatric fracture management

British Society for Children’s Orthopaedic Surgery (BSCOS) guidance suggests that no referral/follow up is required for many fractures of the clavicle, elbow, wrist and toes where there is no or minimal displacement3.

The FORCE study found in children with a torus fracture of the distal radius there was no difference in outcomes between those who were offered of a bandage and immediate discharge (as per UK National Institute for Health and Clinical Excellence recommendations) and those receiving current treatment of rigid immobilisation and follow-up4.

One study in Scotland found that uncomplicated paediatric clavicle fractures can be managed without x-rays in the ED as they do not influence ultimate management or add valuable information to clinicians’ assessment5.


  1. Baig MN. (2017) A Review of Epidemiological Distribution of Different Types of Fractures in Paediatric Age. Cureus. 28;9(8):e1624
  2. Marson BA et al. (2021) Trends in hospital admissions for childhood fractures in England. BMJ Paediatr Open. 10;5(1):e001187
  3. Modifiable Templates for Management of Common Fractures. https://www.bscos.org.uk/public/resources.
  4. Perry DC et al. (2022). Immobilisation of torus fractures of the wrist in children (FORCE): a randomised controlled equivalence trial in the UK. Lancet; 400(10345):39-47
  5. Lirette MP et al. (2018) Can paediatric emergency clinicians identify and manage clavicle fractures without radiographs in the emergency department? A prospective study. BMJ Paediatr Open. 10;2(1):e000304.

Background (continued)

Manipulation of paediatric fractures

A GIRFT report on Paediatric Trauma and Orthopaedic Surgery found that over 250 weeks of operating time a year had been dedicated to manipulation of the forearm and wrist between 2016 and 20191. A significant proportion of these displaced or angulated wrist fractures could have been manipulated and cast in the emergency department rather than being admitted and treated in the operating theatre. The GIRFT report found significant variation between trusts in the number of manipulating being performed in theatre; if this number was reduced to the level in trusts with well-developed ED manipulation protocols, there would be an 80% (equivalent this number could be reduced by 80% (to 57 weeks or less).

Due to pressures on hospitals from the COVID-19 pandemic the British Orthopaedic Association developed guidelines for the early management of distal forearm fractures in children. A study conducted at one trust found following the implementation of these guidelines resulted in 86% of distal forearm fractures in children were manipulated in the ED, an increase from 32% prior to the COVID pandemic2. This saved approximately 63 hours of theatre time in the six-month study period.

The GIRFT report highlighted reluctance to perform procedures in the emergency department because of worries about breach times, a lack of space/facilities to perform sedation and a lack of familiarity with techniques1.




  1. Paediatric Trauma and Orthopaedic Surgery. GIRFT Programme National Specialty Report. April 2022. https://gettingitrightfirsttime.co.uk/girft-reports/
  2. Fink BE etal (2023) Early Management of Paediatric Wrist and Forearm Fractures in a Busy District General Hospital Emergency Department: A Retrospective Cohort Comparison Study and Audit of BOAST Guidelines. Cureus. 15(7):e41325.

Aims


  1. Update and add to the information in the literature on the epidemiology/incidence rate of various paediatric fractures (toe, clavicle, wrist and elbow) in England.

  2. Understand the trends in management of these fracture types over time, e.g. have changes in guidance during COVID-19 changed the trends in management of fractures in Emergency departments.

  3. Investigate the variation in management of these fracture types between Trusts, and the potential activity and cost savings if there was more widespread conservative management, such as reducing unnecessary follow-ups appointments and manipulation in the Emergency Department rather than in theatre.

Data sources and Study population

The data was taken from the Emergency care dataset (ECDS) and linked with records in the Outpatient and Admitted Patient Care Episode (APCE) datasets, all accessed through the National Commissioning Data Repository (NCDR).

The study population included all those aged 16 and under that attended an Emergency care centre and had a SNOMED code for closed fractures of toe, clavicle, elbow or wrist recorded (see Appendices A-C for full code lists) in England between April 2018 and March 2024.

We have focused on closed fractures as this is where there is scope for more conservative management; we have excluded open, pathological, osteoporotic and birth trauma fractures, alongside fractures of the great toe which should all be followed up.

Incidence rates were calculated using the Office of National Statistics (ONS) mid-year population estimates of those aged 16 years and under1.

The coding of fractures is not sufficiently detailed and reliable to determine specific fracture types, and thus what would be the appropriate treatment at an individual patient level. However, we could calculate the proportion of children with each fracture type that:

  • received a follow-up appointment
  • had a fracture manipulated in theatre
  • had a fracture manipulated in the emergency department
  • had a referral/appointment for physiotherapy
  • had an X-ray in the emergency department

Full details of the coding used to identify these procedures/attendances is included in Appendix D.

  1. https://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationestimates/datasets/populationestimatesforukenglandandwalesscotlandandnorthernireland

Characteristics of the cohort

 

Clavicle
(N=85,060)

Elbow
(N=120,943)

Forearm
(N=399,469)

Tibia/Fibula
(N=75,462)

Toe
(N=80,590)

Overall
(N=761,524)

Sex

  Female

26,133 (30.7%)

55,231 (45.7%)

155,681 (39.0%)

30,504 (40.4%)

32,924 (40.9%)

300,473 (39.5%)

  Male

58,735 (69.1%)

65,444 (54.1%)

242,918 (60.8%)

44,785 (59.3%)

47,539 (59.0%)

459,421 (60.3%)

  Missing/Unknown

192 (0.2%)

268 (0.2%)

870 (0.2%)

173 (0.2%)

127 (0.2%)

1,630 (0.2%)

Age

  0-4 yrs

23,108 (27.2%)

30,405 (25.1%)

50,685 (12.7%)

34,192 (45.3%)

3,916 (4.9%)

142,306 (18.7%)

  5-10 yrs

25,809 (30.3%)

59,063 (48.8%)

186,458 (46.7%)

16,173 (21.4%)

28,951 (35.9%)

316,454 (41.6%)

  11-16 yrs

36,143 (42.5%)

31,475 (26.0%)

162,326 (40.6%)

25,097 (33.3%)

47,723 (59.2%)

302,764 (39.8%)

Ethnicity

  Asian or Asian British

4,437 (5.2%)

10,589 (8.8%)

25,180 (6.3%)

5,063 (6.7%)

5,042 (6.3%)

50,311 (6.6%)

  Black or Black British

1,965 (2.3%)

2,546 (2.1%)

8,337 (2.1%)

2,400 (3.2%)

2,024 (2.5%)

17,272 (2.3%)

  Mixed

2,645 (3.1%)

4,194 (3.5%)

12,178 (3.0%)

2,838 (3.8%)

2,538 (3.1%)

24,393 (3.2%)

  Other Ethnic Groups

2,334 (2.7%)

3,420 (2.8%)

11,089 (2.8%)

2,387 (3.2%)

2,052 (2.5%)

21,282 (2.8%)

  White

65,499 (77.0%)

89,109 (73.7%)

305,673 (76.5%)

55,781 (73.9%)

61,388 (76.2%)

577,450 (75.8%)

  Missing/Unknown

8,180 (9.6%)

11,085 (9.2%)

37,012 (9.3%)

6,993 (9.3%)

7,546 (9.4%)

70,816 (9.3%)

IMD Quintiles

  1

18,694 (22.0%)

30,818 (25.5%)

93,220 (23.3%)

19,160 (25.4%)

18,685 (23.2%)

180,577 (23.7%)

  2

15,829 (18.6%)

23,744 (19.6%)

77,000 (19.3%)

14,899 (19.7%)

15,425 (19.1%)

146,897 (19.3%)

  3

16,079 (18.9%)

22,125 (18.3%)

74,179 (18.6%)

13,628 (18.1%)

15,020 (18.6%)

141,031 (18.5%)

  4

16,524 (19.4%)

21,601 (17.9%)

74,494 (18.6%)

13,537 (17.9%)

15,050 (18.7%)

141,206 (18.5%)

  5

17,058 (20.1%)

21,426 (17.7%)

76,790 (19.2%)

13,492 (17.9%)

15,758 (19.6%)

144,524 (19.0%)

  Missing/Outside England

876 (1.0%)

1,229 (1.0%)

3,786 (0.9%)

746 (1.0%)

652 (0.8%)

7,289 (1.0%)

Emergency Dept type

  Major Emergency Dept

67,903 (79.8%)

96,949 (80.2%)

304,781 (76.3%)

63,701 (84.4%)

53,158 (66.0%)

586,492 (77.0%)

  Urgent Treatment Centre/Walk in centre

17,149 (20.2%)

23,987 (19.8%)

94,645 (23.7%)

11,743 (15.6%)

27,430 (34.0%)

174,954 (23.0%)

  Mono-specialty Emergency Dept

0 (0%)

0 (0%)

1 (0.0%)

2 (0.0%)

0 (0%)

3 (0.0%)

  Same Day Emergency Care

8 (0.0%)

7 (0.0%)

42 (0.0%)

16 (0.0%)

2 (0.0%)

75 (0.0%)

Day of ED attendance

  Weekday

59,144 (69.5%)

86,766 (71.7%)

290,942 (72.8%)

53,124 (70.4%)

59,828 (74.2%)

549,804 (72.2%)

  Weekend

25,916 (30.5%)

34,177 (28.3%)

108,527 (27.2%)

22,338 (29.6%)

20,762 (25.8%)

211,720 (27.8%)

Time of ED attendance

   Daytime 7am to 7pm

72,998 (85.8%)

101,404 (83.8%)

346,680 (86.8%)

64,593 (85.6%)

70,489 (87.5%)

656,164 (86.2%)

  Nighttime 7pm to 7am

12,062 (14.2%)

19,539 (16.2%)

52,789 (13.2%)

10,869 (14.4%)

10,101 (12.5%)

105,360 (13.8%)

Year of ED attendance

  2018/19

11,757 (13.8%)

16,985 (14.0%)

51,997 (13.0%)

10,094 (13.4%)

10,793 (13.4%)

101,626 (13.3%)

  2019/20

14,565 (17.1%)

21,103 (17.4%)

66,577 (16.7%)

12,711 (16.8%)

14,953 (18.6%)

129,909 (17.1%)

  2020/21

11,612 (13.7%)

16,942 (14.0%)

56,492 (14.1%)

10,719 (14.2%)

9,969 (12.4%)

105,734 (13.9%)

  2021/22

16,739 (19.7%)

21,943 (18.1%)

82,556 (20.7%)

14,190 (18.8%)

15,034 (18.7%)

150,462 (19.8%)

  2022/23

15,119 (17.8%)

21,840 (18.1%)

71,844 (18.0%)

13,740 (18.2%)

14,604 (18.1%)

137,147 (18.0%)

  2023/24

15,268 (17.9%)

22,130 (18.3%)

70,003 (17.5%)

14,008 (18.6%)

15,237 (18.9%)

136,646 (17.9%)

Fracture incidence rates


Annual fracture incidence rates per 100,000 (2023/2024)

Type

Female
0-4 yrs

Female
11-16 yrs

Female
5-10 yrs

Male
0-4 yrs

Male
11-16 yrs

Male
5-10 yrs

Total

Clavicle

131

62

77

131

250

154

136

Elbow

172

95

284

175

174

271

197

Forearm

270

362

786

273

1,024

828

622

Tibia/Fibula

174

71

72

213

171

76

124

Toe

17

160

125

26

281

142

135


Forearm/wrist fractures are the most common followed by elbow fractures.

Incidence rate by age/sex group


Tibia/Fibula fractures are most common in those aged 0-4 years

Elbow fractures are most common in those aged 5-10 years

In the 11-16 year old age group all fracture types are more common in males compared to females, with males aged 11-16 yrs old having the highest incidence of clavicle, forearm and toe fractures.

Most common fracture types (2023/2024)


SNOMED description

Number

Percentage

Closed fracture of radius (disorder)

Forearm

48,043

35.2

Elbow fracture - closed (disorder)

Elbow

18,613

13.6

Closed fracture of radius AND ulna (disorder)

Forearm

17,498

12.8

Closed fracture of clavicle

Clavicle

15,259

11.2

Closed fracture of phalanx of foot (disorder)

Toe

15,232

11.1

Closed fracture of tibia (disorder)

Tibia/Fibula

8,549

6.3

Closed fracture of ulna (disorder)

Forearm

4,347

3.2

Closed supracondylar fracture of humerus (disorder)

Elbow

3,394

2.5

Closed fracture of fibula (disorder)

Tibia/Fibula

3,278

2.4

Closed fracture of tibia AND fibula (disorder)

Tibia/Fibula

2,145

1.6

Closed Monteggia's fracture (disorder)

Elbow

108

0.1

Closed Galeazzi fracture (disorder)

Forearm

65

0.0

Closed fracture of distal end of radius (disorder)

Forearm

23

0.0

Only showing those fracture types recorded 10 or more times


The majority of fractures are recorded within the emergency care dataset under just a few snomed codes.

Incidence of upper limb fractures by ICB (2023/2024)

Incidence of lower limb fractures by ICB (2023/2024)


For all fracture types the incidence rates are high in the Cornwall and Isles of Scilly ICB area. There are also generally high rates of several fracture types in the Gloucester and Hereford and Worcestershire ICB areas.

The fracture incidence rate is generally lowest is the South East of England, particularly in the London area.

Table of incidence rates per 100,000 by ICB (2023/2024)

ICB

Clavicle

Elbow

Forearm

Tibia/Fibula

Toe

Total

NHS Cornwall and the Isles of Scilly Integrated Care Board

220

365

1,136

177

262

2,159

NHS Herefordshire and Worcestershire Integrated Care Board

201

308

1,016

142

269

1,934

NHS Shropshire, Telford and Wrekin Integrated Care Board

215

292

971

139

230

1,847

NHS Gloucestershire Integrated Care Board

222

186

1,004

183

205

1,800

NHS Derby and Derbyshire Integrated Care Board

185

256

905

169

232

1,747

NHS Somerset Integrated Care Board

195

280

925

150

190

1,740

NHS Dorset Integrated Care Board

188

280

857

145

194

1,664

NHS South Yorkshire Integrated Care Board

192

305

803

169

193

1,662

NHS Norfolk and Waveney Integrated Care Board

198

281

842

167

165

1,653

NHS Devon Integrated Care Board

188

262

871

163

150

1,634

NHS Black Country Integrated Care Board

164

304

818

148

144

1,578

NHS Sussex Integrated Care Board

162

241

825

128

171

1,528

NHS North East and North Cumbria Integrated Care Board

146

232

748

148

186

1,460

NHS Humber and North Yorkshire Integrated Care Board

187

213

727

136

162

1,425

NHS Lincolnshire Integrated Care Board

146

214

736

134

187

1,417

NHS Coventry and Warwickshire Integrated Care Board

174

189

717

146

149

1,375

NHS Bedfordshire, Luton and Milton Keynes Integrated Care Board

132

246

688

110

146

1,322

NHS Greater Manchester Integrated Care Board

140

196

708

114

164

1,322

NHS Mid and South Essex Integrated Care Board

138

215

660

163

137

1,312

NHS Cheshire and Merseyside Integrated Care Board

150

221

661

139

141

1,311

NHS Hampshire and Isle of Wight Integrated Care Board

134

231

638

139

125

1,267

NHS West Yorkshire Integrated Care Board

156

200

621

132

133

1,243

NHS Birmingham and Solihull Integrated Care Board

127

236

603

123

142

1,232

NHS Bristol, North Somerset and South Gloucestershire Integrated Care Board

125

226

589

177

91

1,208

NHS Nottingham and Nottinghamshire Integrated Care Board

131

216

597

150

114

1,208

NHS Northamptonshire Integrated Care Board

144

202

578

97

118

1,139

NHS Bath and North East Somerset, Swindon and Wiltshire Integrated Care Board

145

191

571

116

94

1,117

NHS South West London Integrated Care Board

130

111

569

149

141

1,101

NHS Cambridgeshire and Peterborough Integrated Care Board

146

179

550

99

120

1,094

NHS Suffolk and North East Essex Integrated Care Board

145

157

523

106

129

1,060

NHS Lancashire and South Cumbria Integrated Care Board

122

170

530

124

107

1,052

NHS Hertfordshire and West Essex Integrated Care Board

110

150

506

100

113

980

NHS Surrey Heartlands Integrated Care Board

130

162

460

102

115

970

NHS Leicester, Leicestershire and Rutland Integrated Care Board

99

168

446

128

94

934

NHS Staffordshire and Stoke-on-Trent Integrated Care Board

87

121

503

88

125

923

NHS North Central London Integrated Care Board

92

135

438

107

92

864

NHS Kent and Medway Integrated Care Board

85

104

440

63

109

801

NHS North West London Integrated Care Board

82

132

393

88

74

770

NHS Buckinghamshire, Oxfordshire and Berkshire West Integrated Care Board

84

116

356

78

55

689

NHS Frimley Integrated Care Board

70

118

327

77

46

639

NHS South East London Integrated Care Board

62

103

293

72

69

598

NHS North East London Integrated Care Board

59

121

276

80

47

584

Proportion of ED attendances with a fracture code (2022/2023)

Number of fractures per 10,000 emergency care attendances in those age 16 or under for each provider.

There is considerable variability between providers in the number fractures seen per 10,000 emergency care attendances.

These differences could be due - Alternative provision locally e.g. Very few children attend the Royal Liverpool hospital with fractures as it is located close to Alder Hey, a specialist paediatric centre. - Difference in fracture rate in different area e.g. higher rates in Cornwall and generally lower rate in the London area - Coding/reporting issues resulting in not all fractures being recorded in the emergency departments.

Summary of analysis of incidence rates

Percentage of fractures with a follow-up appointment


There is a trend towards a reduction in the proportion of emergency department attendances for upper limb fractures where a follow-up appointment is given.

Proportion of face-to-face vs virtual follow-up appointments


As a result of the COVID-19 pandemic the proportion of follow up appointments conducted face to face has fallen significantly.

Proportion of follow-up appointments with/without procedure


Over time the proportion of patients with a fracture that have a follow-up appointment with a procedure recorded has decreased, especially following COVID-19, which may be linked to an increase in virtual follow-up appointments.

The proportion of patients with a follow-up appointment with no procedures recorded has remained relatively stable over time. Although for Tibia/Fibula and Elbow fractures there was a slight increase in the proportion of these follow-ups at the start of the pandemic and this increase remained compared to the pre-pandemic period.

Type of outpatient procedures recorded.


These are the most common types of procedures recorded during follow-up appointments. It is common for children to have more than one type of procedure recorded.

The majority of procedures are related to casts/bandages/splints.

Procedures of joint (OPCS code W92) includes: Distension of joint, Examination of joint including under image intensifier or anaesthetic, Chemical or Radiation synovectomy

The number of manipulations recorded is extremely small.

Percentage of fractures manipulated in the ED


The percentage of forearm fractures manipulated in the emergency department has increased over the last 6 yrs, with a large increase seen during the COVID-19 pandemic. There is also a noticeable seasonal trend with a greater percentage of fractures manipulated in the emergency department during the summer months.

The percentage of tibia/fibula fractures manipulated in the emergency department has also increased, but there is little change in the other fracture types over time.

Percentage of fractures manipulated in theatre


The percentage of forearm fractures manipulated in theatre has decreased significantly over the last 6 yrs, with a greater percentage of fractures manipulated in theatre during the summer months.

The percentage of tibia/fibula fractures manipulated in theatre as also decreased.

Proportion of fractures manipulated in ED vs theatre

Over the last 6 years the proportion of manipulations in theatre compared to the emergency department has decreased; currently over half of all manipulations are performed in the emergency department.

There does appear to be a decrease in the total number of fractures being manipulated either in ED or theatre, especially for forearm fractures.

Percentage of fractures referred for physiotherapy


The percentage of emergency department attendances for fractures that result in a referral/outpatient attendance for physiotherapy are higher for those with Elbow and Tibia/Fibula fractures, but generally very low for the other fracture types.

The number of elbow fractures referred to physiotherapy has decreased over the last 6 years, while the number of tibia/fibula fractures referred has increased.

Percentage of fractures with a X-ray recorded in the ED


The majority of fractures of all types are x-rayed in the emergency department, although the percentage of toe fractures x-rayed is slightly lower.

Use of emergency depts vs urgent treatment/walk-in centres


There is a trend towards a greater proportion of fractures being seen in urgent treatment/ walk-in centres rather than emergency departments.

It could be hypothesised that if the proportion of fractures seen in the emergency department continues to decrease that the opportunities to increase manipulations of fractures in the emergency department could become more limited over time.

Manipulations in ED vs Urgent treatment centres (2022/23)

As would be expected those attending emergency departments rather than urgent treatment centres are more likely to have there fractures manipulated in the emergency department.

The percentage of fractures manipulated in theatre is higher for those attending emergency departments, suggesting those with more obvious/complex fractures that are more likely to require manipulation are more likely to attend emergency departments, or be sent there from urgent treatment centres (in a small number of cases where a child attended 2 emergency care sites on the same day, we have only included the second attendance).



In 2022/23, 73% of fractures were seen in the emergency department, and 27% in urgent treatment centres.

However, 90% of fractures requiring manipulations were seen in the emergency department and around 10% in urgent treatment centres, further indicating that those with fractures that require manipulation are more likely to attend an emergency department rather than an urgent treatment centre.

:::

Follow-ups for those attending ED vs Urgent treatment centres (2022/23)

The percentage of fractures where a follow-up appointment is given is broadly similar at urgent treatment centres and emergency departments.

Factors influencing whether a follow-up appointment is given

Odds Ratio

Confidence Intervals

P value

(Intercept)

1.79

1.75 to 1.82

<0.001*

Sex

Female

1.00

Reference

Male

1.12

1.11 to 1.13

<0.001*

Age

5-10 yrs

1.00

Reference

0-4 yrs

0.95

0.94 to 0.97

<0.001*

11-16 yrs

1.15

1.13 to 1.16

<0.001*

Ethnicity

White

1.00

Reference

Asian or Asian British

1.05

1.03 to 1.07

<0.001*

Black or Black British

1.15

1.11 to 1.2

<0.001*

Mixed

1.03

1 to 1.06

0.05

Other Ethnic Groups

1.01

0.98 to 1.05

0.35

Missing/Unknown

0.97

0.96 to 0.99

<0.001*

IMD Quintiles

3

1.00

Reference

1

0.97

0.95 to 0.98

<0.001*

2

1.06

1.04 to 1.08

<0.001*

4

1.03

1.01 to 1.04

<0.001*

5

1.06

1.04 to 1.08

<0.001*

Department type

Major Emergency Department

1.00

Reference

Urgent Treatment Centre/Walk in centre

0.94

0.93 to 0.95

<0.001*

Day of the week

Week

1.00

Reference

Weekend

1.07

1.06 to 1.08

<0.001*

Time of day

Day 7am-7pm

1.00

Reference

Night 7pm to 7am

1.12

1.1 to 1.13

<0.001*

Time of year

Autumn

1.00

Reference

Spring

0.95

0.94 to 0.97

<0.001*

Summer

0.99

0.97 to 1

0.05

Winter

0.95

0.93 to 0.96

<0.001*

Year

2021/22

1.00

Reference

2018/19

1.39

1.36 to 1.41

<0.001*

2019/20

1.27

1.25 to 1.29

<0.001*

2020/21

1.08

1.06 to 1.1

<0.001*

2022/23

0.92

0.9 to 0.93

<0.001*

2023/24

0.92

0.9 to 0.93

<0.001*

Fracture type

Forearm

1.00

Reference

Clavicle

0.79

0.77 to 0.8

<0.001*

Elbow

2.51

2.46 to 2.55

<0.001*

Tibia/Fibula

2.04

2 to 2.08

<0.001*

Toe

0.36

0.35 to 0.36

<0.001*

Children are more likely to be given a follow-up appointment if they are

  • male

  • 11-16 yrs old

  • from an Asian or Black background

  • are not living in an area in the most deprived quintile

They are also more likely to have a follow-up appointment if they attended

  • an emergency department

  • on a weekend

  • at nighttime

Those attending in more recent years were less likely to have a follow-up appointment, further indicating there has been a move towards fewer follow-up appointments.

Factors influencing manipulation of forearm fractures in theatre

Odds Ratio

Confidence Intervals

P value

(Intercept)

1.87

1.71 to 2.06

<0.001*

Sex

Female

1.00

Reference

Male

0.92

0.87 to 0.97

<0.001*

Age

5-10 yrs

1.00

Reference

0-4 yrs

1.58

1.46 to 1.72

<0.001*

11-16 yrs

0.52

0.5 to 0.55

<0.001*

Ethnicity

White

1.00

Reference

Asian or Asian British

0.83

0.74 to 0.92

<0.001*

Black or Black British

0.57

0.49 to 0.68

<0.001*

Mixed

0.71

0.62 to 0.81

<0.001*

Other Ethnic Groups

0.58

0.51 to 0.67

<0.001*

Missing/Unknown

0.84

0.78 to 0.92

<0.001*

IMD Quintiles

3

1.00

Reference

1

1.34

1.25 to 1.45

<0.001*

2

1.06

0.98 to 1.14

0.14

4

0.97

0.9 to 1.04

0.41

5

0.90

0.83 to 0.97

<0.001*

Department type

Major Emergency Department

1.00

Reference

Urgent Treatment Centre/Walk in centre

4.78

4.28 to 5.34

<0.001*

Day of the week

Week

1.00

Reference

Weekend

1.08

1.03 to 1.14

<0.001*

Time of day

Day 7am-7pm

1.00

Reference

Night 7pm to 7am

1.13

1.05 to 1.2

<0.001*

Time of year

Autumn

1.00

Reference

Spring

1.06

0.99 to 1.13

0.1

Summer

1.16

1.09 to 1.23

<0.001*

Winter

0.84

0.77 to 0.91

<0.001*

Year

2021/22

1.00

Reference

2018/19

3.27

2.99 to 3.58

<0.001*

2019/20

2.36

2.18 to 2.56

<0.001*

2020/21

1.05

0.97 to 1.13

0.23

2022/23

0.68

0.63 to 0.74

<0.001*

2023/24

0.50

0.47 to 0.54

<0.001*

Includes only forearm fractures that are manipulated in either the emergency department or in theatre to determine what factors might be influencing the decision to manipulate a fracture in theatre rather than in the emergency department.

Children are more likely to have a fracture manipulated in theatre if they are

  • female

  • under the age of 5

  • white

  • from an area in the most deprived quintile

They are also more likely to have a manipulation in theatre if they attended

  • an urgent treatment centre

  • on a weekend

  • at nighttime

  • in the summer

Those attending in more recent years were less likely to have their fracture manipulated in theatre, further indicating there has been a move towards manipulating more fractures in the emergency department.

Summary of management of fractures

Those presenting at night and at weekends were more likely to have follow up appointments and have their fracture manipulated in theatre. While it may be that those with more obviously/complex fractures that require manipulation or follow up may be more likely to present at these times, rather than perhaps waiting until the next day, it is likely also the result of less senior staff available at these times.

Those attending urgent treatment centres are more likely to have their fractures manipulated in theatre as this would likely not be possible at an urgent treatment centre. There is a trend for more fractures to be seen in urgent treatment centres, and while it appears that most of the fractures requiring manipulation are seen in ED rather than UTCs, a continued trend to seeing more fractures in UTCs may in the future impact the ability of trusts to further move away from manipulations in theatre.

We find the overall manipulation rate for forearm fractures has reduced over the last 6 years, this likely reflects a change in the culture, with displaced fractures now less likely to be manipulated. Indeed, the CRAFFT study is currently looking at whether there is a difference in outcomes between surgical reduction versus non-surgical casting for displaced distal radius fractures in children1.

  1. https://crafft-study.digitrial.com/

Calculating proportions by trust


Includes only NHS trusts that had a total of number of attendances for fractures of over 120 in 2022/23; this resulted in 8 trusts being excluded. Some trusts may have low numbers due to alternative provisions locally e.g. Royal Liverpool had small numbers which is unsurprising given its proximity to a specialist paediatric provision at Alder Hey. Independent providers were also excluded, that majority of these had small numbers of attendances for fractures, i.e. <120 per year.


Overall numbers and percentages for 2022/2023

No. of fractures

No. X-rayed in ED

No. with follow-up

No. with follow-up & no procedure

No. with follow-up with procedure

No. manipulated in theatre

No. manipulated in ED

Clavicle

15,119

13,149 (87%)

9,174 (60.7%)

8,392 (55.5%)

782 (5.2%)

8 (0.1%)

10 (0.1%)

Elbow

21,840

19,193 (87.9%)

17,707 (81.1%)

13,670 (62.6%)

4,037 (18.5%)

258 (1.2%)

189 (0.9%)

Forearm

71,844

62,679 (87.2%)

46,224 (64.3%)

35,532 (49.5%)

10,692 (14.9%)

3,024 (4.2%)

2,908 (4%)

Tibia/Fibula

13,740

11,709 (85.2%)

10,893 (79.3%)

8,158 (59.4%)

2,735 (19.9%)

317 (2.3%)

166 (1.2%)

Toe

14,604

11,117 (76.1%)

6,407 (43.9%)

5,831 (39.9%)

576 (3.9%)

9 (0.1%)

178 (1.2%)

When considering potential savings in terms of follow-up appointments, we have considered only those follow-up appointments that do not include procedures, as all those with procedures are considered necessary.

X-rays for Clavicle and Toes fractures by trust

Min

5.9 %

1st quartile

87.7 %

Median

93.2 %

3rd quartile

95.7 %

Max

100 %

If all trusts reduced the percentage of x-rays to the level of the lowest decile of trusts (77.3%) there would be an annual reduction in England of 1,986 (15.5%) x-rays in emergency departments/urgent treatment centres.

Min

2.4 %

1st quartile

72.6 %

Median

82.4 %

3rd quartile

89.7 %

Max

100 %

If all trusts reduced the percentage of x-rays to the level of the lowest decile of trusts (62.3%) there would be an annual reduction in England of 2,412 (22.5%) x-rays in emergency departments/urgent treatment centres.

Cost savings of reducing x-rays for clavicle and toe fractures

Clavicle fracture

Toe fractures

All attendances at urgent treatment centres are costed at £85 regardless on whether a fracture is x-rayed.

For both Clavicle and Toe fractures without an X-ray the median cost of an emergency department attendance is £126 compared to a median cost of £184 when the fracture is X-rayed, giving a difference of 58

So an annual reduction in Clavicle and Toe X-rays of 4,398 would equate to a saving of £2.55084^{5}

Cost savings of increasing manipulations in theatre

Those not manipulated in the emergency department are those that are manipulated but in theatre.

For both Clavicle and Toe fractures without an X-ray the median cost of an emergency care attendance is £126 compared to a median cost of £184 when the fracture is X-rayed, giving a difference of NA

So an annual reduction in Clavicle and Toe X-rays of 4,398 would equate to a saving of £NA

Upper limb fractures with follow-up by trust (2022/23)

Min

1.5 %

1st quartile

38.4 %

Median

51.1 %

3rd quartile

64.9 %

Max

88.2 %

If all trusts reduced the percentage of follow-ups to the level of the lowest decile of trusts (1.3%) there would be an annual reduction in England of 32,713 (95.1%) follow-up appointments.

Min

2.7 %

1st quartile

51.2 %

Median

65.1 %

3rd quartile

76.6 %

Max

94.6 %

If all trusts reduced the percentage of follow-ups to the level of the lowest decile of trusts (2%) there would be an annual reduction in England of 12,631 (94.2%) follow-up appointments.

Min

5 %

1st quartile

39.4 %

Median

58.7 %

3rd quartile

79.6 %

Max

95 %

If all trusts reduced the percentage of follow-ups to the level of the lowest decile of trusts (2.8%) there would be an annual reduction in England of 7,419 (91.1%) follow-up appointments.

Lower limb fractures with follow-up by trust (2022/23)

Min

6.2 %

1st quartile

47.5 %

Median

61.4 %

3rd quartile

76 %

Max

100 %

If all trusts reduced the percentage of follow-ups to the level of the lowest decile of trusts (4.4%) there would be an annual reduction in England of 6,956 (87.1%) follow-up appointments.

Min

4.2 %

1st quartile

28.7 %

Median

43.7 %

3rd quartile

53.5 %

Max

84.9 %

If all trusts reduced the percentage of follow-ups to the level of the lowest decile of trusts (2.3%) there would be an annual reduction in England of 5,051 (90.3%) follow-up appointments.




Combining the potential reduction in the number of follow-up appointments for all of the fracture types included in this study, there could be a total annual reduction of 64,770 follow-up appointments in England.

Follow-up costs

Comparing GIRFT/Model Hospital metric to our data- 2022/23

Firstly, there are some significant differences between the data included by GIRFT/Model Hospital and the data used in this study, GIRFT/Model Hospital:

  • include all forearm and wrist fractures, whereas we excluded certain fracture types, e.g open fractures which are assumed to all require treatment in theatre.

  • include re-manipulations in theatre, whilst we have excluded these.

  • use a 3-year average, whilst we used only the most recent year where follow-up data is available (2022/23).

The GIRFT/Model Hospital metric uses the total A&E attendances for those aged 16 and under as the denominator. However, since we find incidence rates vary by region, it is likely the proportion of A&E attendances for fractures also vary by region. Therefore to determine variability by trust we using the number of each fracture type as the denominator.

Using fracture number vs total emergency department attendances as the denominator

Using the GIRFT/Model Hospital denominator of A&E attendances The Royal Cornwall Hospitals Trust has a manipulation rate of ~16.6 forearm manipulations/10,000 A&E attendances, putting it the 4th quartile with the 10th highest rate. Using our metric with the number of forearm fractures as the denominator we find 5.9% of forearm fractures are manipulated in theatre, putting The Royal Cornwall Hospitals Trust within the 3rd quartile (39th highest). This is unsurprising given the Cornwall ICB area has a high forearm fracture rate compared to many other regions.

Conversely, Lewisham and Greenwich NHS Trust is in one of the ICB areas with the lowest forearm fracture rates. Using the GIRFT metric this trust has 3.1 manipulations per 10,000 A&E attendances, putting it within the 2nd quartile (41st lowest). With our metric it has 5.1% of fractures manipulated in theatre and is within the 3rd quartile.

At Royal Cornwall Hospitals NHS Trust forearm fractures make up 2.8% of all emergency department attendances, while at Lewisham and Greenwich NHS Trust forearm fractures make up just 0.6% of attendances.

Generally, there are greater discrepancies between the 2 metrics at the higher end, with a greater proportion of manipulations in theatre.

Forearm fractures manipulated in theatre by trust (2022/23)

Min

0.2 %

1st quartile

2 %

Median

3.9 %

3rd quartile

6.3 %

Max

21.4 %

Manipulation in theatre

Min

2.4 %

1st quartile

27 %

Median

58.8 %

3rd quartile

85.4 %

Max

100 %

There could be an annual reduction in England of 1,726 (57.8 %) manipulations in theatre, if all trusts reduced their percentage to the level of the lowest quartile (2%).

Elbow fractures manipulated in theatre by trust (2022/23)

NOTE: Very low numbers at many providers

Min

0 %

1st quartile

0.5 %

Median

1.1 %

3rd quartile

2 %

Max

8.8 %

Manipulation in theatre

Min

0 %

1st quartile

33.3 %

Median

60 %

3rd quartile

100 %

Max

100 %

There could be an annual reduction in England of 167 (66.3%) manipulations in theatre, if all trusts reduced their percentage to the level of the lowest quartile (0.5%). This size of reduction is unlikely to have a significant impact in freeing up theatre time.

Limitations

Some of the variability in the number of fractures, x-rays, physiotherapy referrals, follow-up appointments and manipulations in both theatre and the emergency department could be due to issues with the coding/reporting. For example the number of elbow manipulations recorded in theatre is much lower than would be expected.

Notes

Nottingham University Hospitals NHS Trust, has one of the low proportions of forearm fractures manipulated in theatre, 0.5% in 2022/2023 (while 11.81% were manipulated in the emergency department) meaning only 4% of all forearm manipulations where done in theatre. In term of follow-up appointments 57% of forearm fractures receive a follow-up appointment, which is just above the lowest quartile.

Appendix A- Forearm fracture SNOMED codes

208388003

Fracture at wrist and/or hand level (disorder)

209264008

Closed fracture dislocation of wrist (disorder)

209265009

Closed fracture dislocation distal radioulnar joint (disorder)

209284007

Closed fracture subluxation of distal radioulnar joint (disorder)

67730008

Closed Bennett's fracture (disorder)

307713000

Closed Barton's fracture (disorder)

208324004

Closed dorsal Barton's fracture (disorder)

208323005

Closed volar Barton's fracture (disorder)

209283001

Closed fracture subluxation of the wrist (disorder)

263102004

Fracture subluxation of wrist (disorder)

61653009

Bennett's fracture (disorder)

263103009

Fracture subluxation of distal radioulnar joint (disorder)

1290784005

Stress fracture of bone of wrist region (disorder)

1303397005

Fracture of bone of wrist region (disorder)

1285722006

Fracture of distal end of left ulna (disorder)

14430001000004100

Fracture of distal end of right ulna (disorder)

27094009

Skillern's fracture (disorder)

281530009

Fracture of ulnar styloid (disorder)

41036008

Closed fracture of styloid process of ulna (disorder)

263208005

Fracture of distal end of radius and ulna (disorder)

33192001

Closed fracture of lower end of radius AND ulna (disorder)

50397009

Closed fracture of distal end of ulna (disorder)

208318005

Closed fracture of ulna, lower epiphysis (disorder)

6163002

Closed fracture of head of ulna (disorder)

263199001

Fracture of distal end of radius (disorder)

58722007

Moore's fracture (disorder)

448355005

Greenstick fracture of distal radius (disorder)

737262009

Fracture of lower end of radius with volar tilt (disorder)

737261002

Fracture of lower end of radius with dorsal tilt (disorder)

123972004

Reversed Colles' fracture (disorder)

123618009

Closed reverse Colles' fracture (disorder)

281527002

Fracture of radial styloid (disorder)

208325003

Closed fracture radial styloid (disorder)

426467005

Hutchinson's fracture (disorder)

18310001000004100

Fracture of distal end of right radius (disorder)

16542901000119100

Closed fracture of metaphysis of distal end of right radius (disorder)

1285724007

Fracture of distal end of left radius (disorder)

16542861000119100

Closed fracture of metaphysis of distal end of left radius (disorder)

123971006

Colles' fracture (disorder)

269083002

Closed Colles' fracture (disorder)

17222009

Closed fracture of distal end of radius (disorder)

448838000

Closed extraarticular fracture of distal radius (disorder)

208326002

Closed fracture distal radius, intra-articular, die-punch (disorder)

704212006

Closed fracture of distal epiphysis of radius (disorder)

1279881008

Closed fracture of metaphysis of distal end of radius (disorder)

35442005

Closed fracture of lower end of forearm (disorder)

307172007

Fracture dislocation distal radioulnar joint (disorder)

1264544004

Fracture of bone adjacent to prosthesis of wrist joint (disorder)

12217801000119100

Fracture of bone adjacent to prosthesis of left wrist joint (disorder)

12202711000119100

Fracture of bone adjacent to prosthesis of right wrist joint (disorder)

1303394003

Fracture of bone of left wrist region (disorder)

1303396001

Fracture of bone of bilateral wrist regions (disorder)

1303395002

Fracture of bone of right wrist region (disorder)

46773004

Quervain's fracture (disorder)

3228009

Closed fracture of shaft of radius (disorder)

12676007

Fracture of radius (disorder)

28078000

Closed fracture of shaft of bone of forearm (disorder)

53627009

Closed fracture of radius AND ulna (disorder)

53792000

Closed fracture of shaft of ulna (disorder)

54556006

Fracture of ulna (disorder)

54645004

Barton's fracture (disorder)

54819005

Closed fracture of shaft of radius and ulna (disorder)

65966004

Fracture of forearm (disorder)

71555008

Closed fracture of ulna (disorder)

75857000

Fracture of radius AND ulna (disorder)

91419009

Closed fracture of forearm (disorder)

111640008

Closed fracture of radius (disorder)

208309008

Closed fracture radius and ulna, middle (disorder)

208322000

Closed Galeazzi fracture (disorder)

208513000

Multiple fractures of forearm (disorder)

263198009

Fracture of shaft of radius (disorder)

263200003

Volar Barton's fracture (disorder)

263201004

Dorsal Barton's fracture (disorder)

263204007

Fracture of shaft of ulna (disorder)

263205008

Fracture of distal end of ulna (disorder)

263207000

Fracture of shaft of radius and/or ulna (disorder)

268824003

Fracture of radius and/or ulna due to birth trauma (disorder)

271576001

Galeazzi fracture dislocation (disorder)

281528007

Fracture of olecranon (disorder)

281529004

Fracture of coronoid process of ulna (disorder)

287074009

Fracture malunion - forearm (disorder)

390986009

Torus fracture of radius (disorder)

429655000

Closed torus fracture of radius (disorder)

704056001

Stress fracture of ulna (disorder)

704059008

Stress fracture of radius (disorder)

733235002

Fracture of shaft of ulna and radius (disorder)

1285721004

Fracture of right ulna (disorder)

1303390007

Fracture of bone of left forearm (disorder)

1303391006

Fracture of bone of right forearm (disorder)

446461000124103

Fracture of right radius (disorder)

12960001000004100

Fracture of left radius (disorder)

13270001000004100

Fracture of left ulna (disorder)

Appendix B- Elbow and Clavicle fracture SNOMED codes

Elbow

123973009

Monteggia's fracture (disorder)

1303382007

Fracture of left olecranon (disorder)

1303383002

Fracture of right olecranon (disorder)

1303392004

Fracture of bone of left elbow joint region (disorder)

1303393009

Fracture of bone of right elbow joint region (disorder)

16866431000119100

Closed fracture of capitellum of right humerus (disorder)

16867081000119100

Closed fracture of capitellum of left humerus (disorder)

19259001

Closed fracture of upper end of radius AND ulna (disorder)

208267005

Closed fracture distal humerus, lateral condyle (disorder)

208270009

Closed fracture of distal humerus, trochlea (disorder)

208271008

Closed fracture distal humerus, lateral epicondyle (disorder)

208272001

Closed fracture distal humerus, capitellum (disorder)

208273006

Closed fracture distal humerus, bicondylar (T-Y fracture) (disorder)

208274000

Multiple closed fractures of distal humerus (disorder)

208294009

Closed fracture olecranon, extra-articular (disorder)

208295005

Closed fracture of proximal ulna, comminuted (disorder)

208296006

Closed fracture proximal radius, comminuted (disorder)

208298007

Closed fracture olecranon, intra-articular (disorder)

209252000

Closed fracture dislocation elbow joint (disorder)

209253005

Closed fracture dislocation superior radioulnar joint (disorder)

209258001

Closed fracture subluxation of elbow joint (disorder)

209259009

Closed fracture subluxation superior radioulnar joint (disorder)

21419000

Closed fracture of medial condyle of humerus (disorder)

2295008

Closed fracture of upper end of forearm (disorder)

263078002

Fracture dislocation of elbow joint (disorder)

263100007

Fracture subluxation of elbow joint (disorder)

263101006

Fracture subluxation of superior radioulnar joint (disorder)

263192005

Fracture of distal end of humerus (disorder)

263193000

Supracondylar fracture of humerus (disorder)

263195007

Fracture of proximal end of radius (disorder)

263196008

Fracture of radial head (disorder)

263197004

Fracture of radial neck (disorder)

263203001

Fracture of proximal end of ulna (disorder)

263206009

Fracture of proximal end of radius and ulna (disorder)

269080004

Closed fracture of the distal humerus (disorder)

281525005

Fracture of the lateral humeral epicondyle (disorder)

281526006

Fracture of the medial humeral epicondyle (disorder)

29045004

Closed Monteggia's fracture (disorder)

302222008

Elbow fracture - closed (disorder)

309464009

Elbow fracture (disorder) 

33041006

Closed fracture of proximal end of ulna (disorder)

440366004

Closed fracture of the medial epicondyle of humerus (disorder)

441496000

Transcondylar fracture of distal humerus (disorder)

442448003

Fracture of head of radius with dislocation of distal radioulnar joint and interosseous membrane disruption (disorder)

58580000

Closed supracondylar fracture of humerus (disorder)

5895007

Closed multiple fractures of upper end of radius (disorder)

64902007

Closed fracture of olecranon process of ulna (disorder)

68819003

Closed fracture of coronoid process of ulna (disorder)

68854005

Closed fracture of head of radius (disorder)

700147004

Avulsion fracture of medial epicondyle of humerus (disorder)

704208000

Closed fracture of proximal epiphysis of radius (disorder)

704410001

Closed transcondylar fracture of distal humerus (disorder)

705076001

Closed fracture of epiphyseal plate of distal humerus (disorder)

71139009

Closed fracture of proximal end of radius (disorder)

72497001

Closed fracture of neck of radius (disorder)

733408008

Fracture of lateral condyle of humerus (disorder)

733409000

Fracture of medial condyle of humerus (disorder)

7341005

Closed multiple fractures of upper end of ulna (disorder)

80767005

Closed fracture of condyle of humerus (disorder)

Clavicle

58150001

Fracture of clavicle

33173003

Closed fracture of clavicle

1658003

Closed fracture of acromial end of clavicle

87376003

Closed fracture of shaft of clavicle

48561006

Closed fracture of sternal end of clavicle

88196000

Fracture of interligamentous part of clavicle (disorder)

1303380004

Fracture of left clavicle (disorder)

1303379002

Fracture of bone of bilateral clavicles (disorder)

1303381000

Fracture of right clavicle (disorder)

41972004

Fracture of shaft of clavicle (disorder)

56642004

Fracture of sternal end of clavicle (disorder) 

733403004

Multiple fractures of clavicle (disorder)

208510002

Multiple fractures of clavicle, scapula and humerus (disorder)

431011000

Nonunion of fracture of clavicle (disorder)

704069002

Stress fracture of clavicle (disorder) 

Appendix C- Tibia/Fibula and Toe fracture SNOMED codes

Tibia/Fibula

31978002

Fracture of tibia (disorder)

6698000

Closed trimalleolar fracture (disorder)

6990005

Fracture of shaft of tibia (disorder)

15385006

Closed fracture of medial malleolus (disorder)

20433007

Fracture of upper end of tibia (disorder)

23900009

Closed fracture of upper end of tibia (disorder)

25899002

Closed bimalleolar fracture (disorder)

28012007

Closed fracture of shaft of tibia (disorder)

47848000

Closed fracture of condyle of tibia (disorder)

71830006

Supination-adduction injury of ankle, stage 2 (disorder)

87905008

Gosselin's fracture (disorder)

123975002

Trimalleolar fracture (disorder)

208610006

Closed fracture proximal tibia, medial condyle (plateau) (disorder)

208611005

Closed fracture proximal tibia, lateral condyle (plateau) (disorder)

208612003

Closed fracture proximal tibia, bicondylar (disorder)

208613008

Closed fracture intercondylar spine of tibia (disorder)

208629000

Closed fracture of tibia and fibula, shaft (disorder)

208634001

Closed fracture distal tibia (disorder)

208635000

Closed fracture distal tibia, extra-articular (disorder)

208636004

Closed fracture distal tibia, intra-articular (disorder)

208662008

Closed fracture ankle, bimalleolar, low fibular fracture (disorder)

208663003

Closed fracture ankle, bimalleolar, high fibular fracture (disorder)

208666006

Closed fracture ankle, trimalleolar, low fibular fracture (disorder)

208667002

Closed fracture ankle, trimalleolar, high fibular fracture (disorder)

263237009

Closed fracture of tibial tuberosity (disorder)

263240009

Pilon fracture (disorder)

263241008

Tillaux fracture (disorder)

263244000

Bimalleolar fracture of ankle (disorder)

271577005

Fracture of shaft of tibia and fibula (disorder)

278537006

Fracture of distal end of tibia (disorder)

281531008

Fracture of medial malleolus (disorder)

281532001

Fracture of posterior malleolus (disorder)

281843000

Fracture of tibial spine (disorder)

413877007

Closed fracture of tibia AND fibula (disorder)

414293001

Fracture of tibia AND fibula (disorder)

428256003

Fracture of condyle of tibia (disorder)

428257007

Fracture of tibial plateau (disorder)

428797006

Closed osteochondral fracture of proximal tibia (disorder)

428798001

Closed fracture of tibial plateau (disorder)

442205007

Stress fracture of tibia (disorder)

445410003

Closed fracture of distal tibia and distal fibula (disorder)

446298003

Closed pilon fracture (disorder)

447139008

Closed fracture of tibia (disorder)

703998005

Closed bicondylar fracture of tibial plateau (disorder)

705080006

Closed fracture of epiphyseal plate of distal tibia (disorder)

705092006

Closed fracture of epiphyseal plate of proximal tibia (disorder)

733295004

Avulsion of tibial tuberosity (disorder)

735669008

Fracture of metaphysis of proximal tibia (disorder)

735671008

Fracture of lateral condyle of tibia (disorder)

735672001

Fracture of medial condyle of tibia (disorder)

735846008

Avulsion of ligament with bony fragment of medial malleolus (disorder)

39541000087106

Fracture of medial condyle of left tibia (disorder)

39551000087109

Fracture of medial condyle of right tibia (disorder)

40031000087104

Fracture of left tibial plateau (disorder)

40041000087105

Fracture of right tibial plateau (disorder)


40051000087108

Fracture of lateral condyle of left tibia (disorder)

40061000087106

Fracture of lateral condyle of right tibia (disorder)

40071000087102

Fracture of left medial malleolus (disorder)

40081000087100

Fracture of right medial malleolus (disorder)

10924841000119100

Closed fracture of medial condyle of right tibia (disorder)

10924881000119100

Closed fracture of medial condyle of left tibia (disorder)

75591007

Fracture of fibula (disorder)

21867001

Fracture of upper end of fibula (disorder)

28359007

Closed fracture of head of fibula (disorder)

34268009

Closed fracture of lateral malleolus (disorder)

59639009

Closed fracture of upper end of fibula (disorder)

67394003

Fracture of shaft of fibula (disorder)

77803008

Closed fracture of shaft of fibula (disorder)

208615001

Closed fracture fibula, neck (disorder)

208657007

Closed fracture ankle, lateral malleolus, low (disorder)

208658002

Closed fracture ankle, lateral malleolus, high (disorder)

263242001

Fracture of distal end of fibula (disorder)

281533006

Fracture of head of fibula (disorder)

281534000

Fracture of neck of fibula (disorder)

281535004

Fracture of lateral malleolus (disorder)

308153009

Closed fracture of distal fibula (disorder)

315643003

Dupuytren's fracture dislocation ankle (disorder)

442538002

Stress fracture of fibula (disorder)

447395005

Closed fracture of fibula (disorder)

704209008

Closed fracture of epiphysis of proximal fibula (disorder)

705082003

Closed fracture of epiphyseal plate of distal fibula (disorder)

733296003

Avulsion of head of fibula (disorder)

735842005

Fracture of lateral malleolus below syndesmosis (disorder)

735844006

Avulsion of ligament with bony fragment of lateral malleolus (disorder)

735845007

Fracture of lateral malleolus at syndesmosis (disorder)

735847004

Fracture of distal fibula above syndesmosis (disorder)

736517000

Avulsion fracture of anterior fibula (disorder)

19350001000004100

Stress fracture of tibia and fibula (disorder)

Toe

21351003

Fracture of phalanx of foot (disorder) 

81576005

Closed fracture of phalanx of foot (disorder)

302036006

Closed fracture dislocation of interphalangeal joint of toe (disorder)

209361003

Closed fracture dislocation of interphalangeal joint of multiple toes (disorder)

209378007

Closed fracture subluxation of interphalangeal joint of multiple toes (disorder)

209359007

Closed fracture dislocation of interphalangeal joint of single toe (disorder)

208712008

Closed fracture distal phalanx, toe (disorder)

705067008

Closed fracture of distal phalanx of lesser toe (disorder)

208711001

Closed fracture middle phalanx, toe (disorder)

705068003

Closed fracture of epiphyseal plate of lesser toe (disorder)

208713003

Closed fracture of multiple phalanges of toe (disorder)

208710000

Closed fracture proximal phalanx, toe (disorder)

704057005

Stress fracture of phalanx of foot (disorder)

11314801000119100

Stress fracture of phalanx of left foot (disorder) 

11314761000119100

Stress fracture of phalanx of right foot (disorder)

263093003

Fracture dislocation of toe joint (disorder)

263117000

Fracture subluxation of interphalangeal joint of toe (disorder)

209375005

Closed fracture subluxation of interphalangeal joint of single toe (disorder)

Fracture of great toe was excluded as this should be followed up- however <10 codes related to the fracture of the great toe were recorded over the whole 6 yr period in England, suggesting that many of these fractures may be coded as ‘Closed fracture of phalanx of foot (disorder)’ and thus included within out dataset.

Appendix D

Manipulation in emergency department identified using A&E Treatment Code:

10- Reduction

Manipulation in theatre was identified by one of the following OPCS codes recorded during an inpatient episode in the 3 months post-emergency care attendance.

  • W262 Manipulation of fracture of bone NEC
  • W268 Other specified
  • W269 Unspecified
  • W663 Primary manipulative closed reduction of fracture dislocation of joint NEC
  • W252 Closed reduction of fracture of bone and fixation using functional bracing system

X-ray in the emergency department was identified using A&E Investigation Code:

01- X-ray

Physiotherapy appointments were identified by one of the following:

  • SNOMED referral code for physiotherapy in ECDS- 306170007 Referral to physiotherapy service (procedure)
  • Treatment Function Code for physiotherapy in the outpatient dataset in the 3 months post-emergency care attendance- 650 Physiotherapy Service

Outpatient follow up appointments were identified using the following codes in the outpatient dataset in the 3 months post-emergency care attendance

Treatment function code was one of:

  • 110 Trauma and orthopaedic service
  • 111 Orthopaedic Service
  • 115 Trauma Surgery Service
  • 214 Paediatric Trauma and Orthopaedic Service

It was also required that the Emergency care attendance discharge information did NOT have the SNOMED code- 3780001 Routine patient disposition, no follow-up planned (procedure)

Appendix E

HRG codes and costings